Airway fire

Introduction

Surgical fires are rare yet potentially devastating events in the operating room and are widely regarded as “never events.” In the United States, an estimated 600 surgical fires occur annually. Through heightened awareness and deliberate preventive practices, operating room teams can significantly reduce the risk of these events and improve patient safety.

Procedures that carry a higher risk of surgical fire include tonsillectomies, tracheostomy creation, burr hole surgery, and surgical removal of lesions involving the head, neck, or face.

Triangle of Surgical Fires

There are 3 basic elements that all contribute equally to the composition of a surgical fire: ignition , oxidizer, and fuel source. Each one of these is required in the proper proportion and condition in order to have a surgical fire.

Ignition Sources:

• Electrocautery (Monopolar, Bipolar, Bovie)
• Lasers
• Fiberoptic Light Source (often used for our bronchoscopic procedure)
• High Speed Drills/Burrs
• Defibrillator

Oxidizer

• Oxygen
  • Oxygen Rich Environments are considered ones where the concentration is greater than 21%.
  • Fires will burn hotter, more vigorously, and spread more rapidly in oxygen rich environments
• Nitrous Oxide
  • Fires with nitrous tend to burn as hot as they do with oxygen enriched environments
• Air

Fuel

• Alcohol (Flammable) Skin Prep
• Drapes/Gowns
• Gauzes
• Sponges
• Dressings
• Patient hair/skin
• ETT

Prevention of Surgical Fires

Minimize Oxidizers

• Whenever feasible, reduce the fraction of inspired oxygen (FiO₂) to less than 30% while still maintaining an adequate oxygen saturation. Lowering oxygen concentration is a key strategy in reducing the risk of surgical fire.
• When planning to use a low FiO₂ (<30%), increase fresh gas flows to facilitate washout of excess oxygen from the breathing circuit. This process may take longer than anticipated; therefore, closely monitor both FiO₂ and end-tidal oxygen (EtO₂) on the ventilator. Ongoing communication with the surgical team during this period is essential.
• Coordinate with the surgical team to identify critical portions of the procedure, particularly when electrocautery will be used near potential oxygen sources. Proactive planning and clear communication can significantly reduce fire risk.

Manage Ignition Source

• During the surgical time-out, communicate with the surgical team to ensure you are notified before electrocautery is used near any oxygen-enriched environment.
• Reinforce that electrocautery should not be used when entering the trachea, as this significantly increases the risk of airway fire.
• When fiberoptic scopes are in use, turn off the light source when the scope is not actively needed, as the tip can continue to heat over time. Additionally, avoid placing fiberoptic scopes on or near potential fuel sources to further reduce fire risks.

Managing Fuel

• When possible, use non–alcohol-based skin preparation solutions, such as iodine-based agents. If alcohol-based preps are required, use the minimal necessary amount and ensure that no solution has pooled. Allow adequate drying time—at least three minutes—before draping or initiating the procedure.
• Remove dry towels from the surgical field and moisten sponges to reduce the availability of potential fuel sources.
• For cases with elevated fire risk, consider the use of a laser-resistant endotracheal tube (ETT). Metallic ETTs, typically constructed from aluminum, offer increased resistance to ignition from laser energy. In contrast, polyvinyl chloride (PVC), red rubber, and silicone endotracheal tubes are more susceptible to ignition during laser airway surgery.
• Inflating the ETT cuff with saline rather than air can further reduce fire risk. Adding a dye such as methylene blue to the saline may aid in early detection of cuff rupture.

Steps to Manage an Airway Fire

1. Turn off any delivery of O2 to the patient
2. Disconnect the breathing circuit and simultaneously remove the ETT
   1. Remember, leaving the ETT in place can cause melting of the tube in the airway
   2. If you do not turn off the oxygen prior to removal of the tube, it can cause a blow torch effect which can turn this airway fire into a surgical fire
3. Pour saline into the airway
4. Remove all additional debris from the airway including (sponges and ETT fragments)
   1. Best to inspect the ETT to ensure that it is still intact and there is no major fragments
5. Once the fire has extinguished, attempt to reestablish ventilation with either the placement of an ETT or Mask Ventilation
   1. Avoid all O2 at this point because there may still be small embers in the airway that could ignite
6. Perform bronchoscopy to assess injury and remove any additional debris that may be lodged deeper in the airway

Resources:

1. ECRI Institute. New clinical guide to surgical fire prevention. Patients can catch fire- here’s how to keep them safer. Health Devices. 2009; 38:314-32. PubMed
2. Apfelbaum JL, et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013;118(2): 271-90. PubMed
3. Miller R Miller's Anesthesia. 7th Edition. 2010. Pages 2405-2416
4. Barash, Clinical Anesthesia, 7th Edition. Pages 210-211.